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Oncology Cheat Sheet (DRAFT) by

Oncology dietetics MNT

This is a draft cheat sheet. It is a work in progress and is not finished yet.

Guidelines & References

ESPEN expert group recomm­end­ations for action against cancer­-re­lated malnut­rition
ESPEN practical guide: Clinical nutrition in cancer
Clinical Oncology Society of Australia. Position statement: Cancer­-re­lated malnut­rition and sarcopenia

Grading

Uses tumour biopsy
X to 4
Higher grade = undiff­ere­ntiated = more intense treatment
Gx = grade cannot be assessed (undet­erm­ined)
G4 = undiff­ere­ntiated (high grade)
undiff­ere­ntiated = cells that don’t look or act like normal cells. They’ve lost their original identity and are very abnormal.
descri­ption of a tumour based on how abnormal the tumour cells look under a micros­cope.
It is an indicator of how quickly the tumour is likely to grow and spread.

Staging

TNM. Higher number = more severe
T = tumour size (1-4). Higher number = larger tumour
N = number of lymph nodes which contain cancer (1-3). Higher number = more lymph nodes affected
M = Distant metast­asised. X = cannot be measured. O = no met. 1 = met.
T4N3M1 = large tumour which has spread signif­icantly to lympth nodes and has metast­asised – will continue to grow & spread rapidly
Not usually used for: Leukaemia, Lymphomas, Myelomas

Termin­ology + acronyms

Benign (nonma­lig­nant) = not cancer
Malignant = cancer
Metastasis = spread of cancer cells
Neoadj­uvant: Treatment given as a first step to shrink a tumour before the main treatment (usually surgery). Includes chemo, radiation or hormone therapy
Adjuvant: Additional treatment given after the primary treatment to lower the risk of the cancer coming back. Includes chemo, radiation, hormones, biological or targeted therapy
Cancer cachexia: uninte­ntional weight and muscle loss in people with cancer, not fully reversible by eating more
Gy: grey - measures radiation
#: fractions - radiation dose - has to be fractioned because one fraction would be too damaging
70Gy/35# = 70 Grey total radiation broken up into 35 #
hypoge­usia: decreased taste sensit­ivity
hyperg­eusia: increased taste sensit­ivity
Phanto­geusia: Perception of an unpleasant taste, without actually eating anything
Breakt­hrough nausea: occurs despite the use of preventive (proph­yla­ctic) antiemetic medica­tions

Types of cancers

Carcinomas
Most common. Arise from epithelia cells. Breast, prostate, lung, colore­ctal, melanoma.
Lymphoma
Cancer of the lymphatic system (hodgkin lymphoma and non- Hodgkin lymphoma)
Leukemia
Cancer of white blood cells, often starting in bone marrow
Multiple myeloma
A cancer of plasma cells in the bone marrow.
Sarcomas
From bone, muscle, fat. Osteos­arcoma (bone), Leiomy­osa­rcoma (smooth muscle tissue)
Gliobl­astoma
An aggressive brain tumor.
Basal Cell Carcinoma (BCC)
Subtype of skin cancer - common - rarely met.

Metabolic Changes

Cachexia + sarcopenia
Due to treatment: stem cells + blood cells depleted - anaemia, impaired blood clotting, more suscep­tible to infections
 

Treatment

Chemo
Oral, IV or injection
 
Stop or slow growth through irreve­rsible damage to the DNA - kills all fast-g­rowing cells - incl healthy cells
 
Given in cycles – gives the healthy cells a chance to grow back. C3D8 = cycle 3 (of 8), Day 8 (of the 14 day cycle)
 
S/E: V&D, consti­pation, dysphagia, fatigue, altered taste, oral thrush, thickened saliva, reflux, dry mouth, mucositis
Immuno­therapy
Helps the patients own immune system to fight cancer Eg. immune checkpoint inhibitors or monoclonal antibodies
 
Not as big effect on nutrition
 
S/E: Diarrhoea, abdo pain, bloating
Radiation (XRT)
Kills or slows the growth of cells by damaging the DNA. In a big machine (linear accele­rator or LINAC), similar to a CT scan. Measured in “grey” and given in “fract­ions”
 
S/S occur after 2 weeks of treatment & accumulate
 
S/E: Fatigue, dysphagia, diarrhea, vomiting, thick salvia, pain, taste changes, damage to bowels (eg bleeding)
 
Internal radiation: radiation is placed inside the body. e.g radioa­ctive iodine liquid (systemic therapy) is used for thyroid cancer.
 
EXTERNAL BEAM RADIATION THERAPY: most common type of radiation.

Interv­ention

Symptom management
Malnut­rition assess­ment: SGA, PG-SGA SF (for chemo)
Malnut­rition screening – MST, MUST
Sarcopenia screening (SARC-F)
HPHE - ONS/Fo­rti­fic­ati­on/EN
Educate: Food safety & hygiene – Immuno­com­pro­mised. Avoid illness
Depending on the person­/pr­ogn­osis: low-in­fla­mmatory foods – more so in people In remission
Consider: site of cancer, refeeding risk, tube position (is it in the right place?)

Nut Reqs

Energy ~125kJ
Chemo & Radiation: >12­5kJ/kg
Cancer cachexia: >12­5kJ/kg
Malnut­rition = repletion (125-1­45kJ)
Protein ~1.2-1.5g
Chemo & Radiation: >1.2­g/kg
Older/­chr­oni­cally ill/re­ple­tion: 1.2-1.5­g/day
Renal failure: 1.0-1.2­g/kg
Cancer cachexia: > 1.4g/kg
SPEN: 2.0-2.2g EPA and 1.5g DHA
SPEN: Leucine 2-4g; HMB 3g; Glutamine 0.3g/kg; Carnitine 4-6g; Creatine 5g
SPEN: 600-800 IU Vitamin D + multiv­ita­min­/mi­nerals

Example PESS

Inadequate oral intake related to loss of appetite and nausea 2 to chemot­herapy, as evidenced by pt consuming ~__% of EER and ___% of EPR*
Food and nutrition knowledge deficit
Inadequate protei­n-e­nergy intake

Medica­tions

Drug
Indication
S/E
ondans­etron
Preven­tion, treatment of nausea, vomiting.
consti­pation, xerostomia
metocl­opr­amide
nausea, vomiting
GI upset, oedema
dexame­thasone
Cortic­ost­eroid
loperamide
Sympto­matic relief of acute nonspe­cific diarrhoea
Lomotil
Opioid. Adjunctive therapy for acute, chronic diarrhoea
Codeine
Opioid analgesic. Short-term management of severe pain
 

Nutrition Strategies – based on S/S

CTCAE Grading 1 to 5. 1 = mild, interv­ention not indicated. 5 = death related to S/S.
Taste Changes
 
tasteless: add salt or seasoning, ginger, pickles, honey, adding herbs/­spices, honey, pickles, marinades, sauces etc. Varied texture and taste (e.g. adding granola, freezing smoothies) - can make the eating experience more exciting. Over-t­he-­counter artificial salivas. Flavour enhancers - e.g. miracle berry.
 
too strong: use straw. No added sugar products. Low salt altern­atives. Avoid fizzy drinks­/mi­nts­/ch­ewing gum
 
Too salty: Roast meats over deli meats. Add sugar or honey to food.
 
Too sweet: Avoid added sugars­/fruit etc. Plain breakfast cereals. Add salt or lemon juice.
 
Metallic: ginger, small sips of flavoured drinks. Non-me­tallic cutlery. Suck on boiled lollies. Brushing teeth just before & after eating. Bicarb mouth wash before eating.
 
Feel like “sand”, “straw” “cardb­oard” – Change the consis­tency of the food, soft, moist foods, add sauces­/gr­avies, soups & smoothies, drink lots of water, medica­tions to replace saliva
 
pink lady – Gaviscon + a numbing agent – pharmacist
Smell changes
 
Ask friend­s/f­amily to cook for you
 
Cook in bulk and freeze
 
Bland foods.
 
Cold or room temp (avoid hot)
 
Avoid strong flavours: garlic, onion etc
N/V
 
Medica­tions – pharmacist
 
Cold or room temp food – usually better tolerated. sandwi­ches, salads, jelly, custard and yoghurt (NEMO)
 
Smaller frequent meals – avoid having an empty stomach Peppermint or ginger
 
Take opioids with crackers or light meal
 
Salty snacks/dry crackers, biscuits, noodles, cereal, toast, pretzels, crackers
 
Avoid skipping meals/­snacks as empty stomach can worsen
 
Avoid alcohol and high volumes of coffee
 
sucking on ice blocks
 
regular small sips of water or cold clear fluids – cordial, lemonade, ginger ale, juice
Mucositis & dysphagia
 
Artificial sweeteners
 
Sugar free gum
 
Avoiding hot food
 
Avoiding sources of trauma – hard toothb­rush, crispy foods
 
Analgesia mouth washes - before food to improve intake
 
Causes to consider: oral thrush, xerostomia
Diarrhoea
 
Medical management – consult medical team/P­har­macist
 
Monitor dehydr­ation & electr­olyte losses
 
ORS (oral rehydr­ation soluti­ons): homemade or double strength hydrolyte
 
Consider non-tr­eatment causes – Fibre, lactose, intole­rances, sugar-free products
 
Limiting fatty/­greasy dishes, high fibre foods and fizzy drinks
 
Bland foods
 
Avoid caffeine
 
Try low lactose altern­atives
 
Excess fructose (e.g. fruit juice) can exacerbate diarrhoea
 
Soluble fibre - psyllium husk - can help bulk the stool
 
temporary Low fibre and/or low FODMAP
 
Monitor for signs of pancreatic exocrine insuff­iciency (fat malabs, greasy stools etc)+ stool tests for infections
Loss of appeti­te/­Ano­rexia
 
Meds: Appetite stimulants
 
HPHE & ONS – Sustagen, up & go, milkshakes etc
 
6 smaller meals/day - use smaller plates
 
Encourage to eat by the clock – avoid waiting until they are hungry
 
Eat when appetite is better – commonly morning
 
Encourage favourite foods – discuss with family
 
Social eating
 
Softer foods that don’t require chewing
 
Cook in bulk and freeze – less exposure to food smells
 
Have ready-­pre­pared meals/­snacks
 
Encourage gentle exercise
 
Consider: mouth sores/­cha­nge­s/i­nfe­cti­ons­?/a­gin­g/other medica­tions, psycho­soical factors
Oral Health/dry mouth
 
Regular sips of water to keep mouth hydrated & stimulates saliva
 
Gum, sucking on lollies
 
Sodium bicarb mouth wash
 
Artificial saliva, alcohol free mouth wash
 
Oral adhering discs
 
Moist foods + sauces and gravies
 
Dry mouth: EVOO: acts as a mouth lubricant
 
Mucositis: Honey + coffee mouth rinse or sip (300g honey + 20g - mix 10ml of honey mixture w/ hot water. Either rinse or sip. 10mL every 3hrs)
Early Satiety
 
Small, frequent nutrient dense meals
 
Avoiding nutrie­nt-free drinks
 
Avoid having fluids with meals - have inbetween
 
Prokin­etics: increase gastric emptying (e.g. metocl­opr­amide, erythr­omycin)
 
Medpass: mall volumes of high-c­alorie, high-p­rotein supple­ments (like fortified shakes) are admini­stered alongside routine medication times.
 
Distra­ction technique - takes some of the focus off food: social eating, calling friends, puzzles, colouring, watching a show, colour­ing­/dr­awi­ng/­pai­nting. Risk of 'forge­tting' about the food - better when someone else is there
 
Nourishing fluids in between meals
 
Causes to consider: delayed gastric emptying, nausea, Medica­tions that slow gastric emptying
Consti­pation
 
Consider other causes: Dehydr­ation, decreased PA, decreased overall intake, hyperc­alc­emia, hypoka­lemia
 
Medica­tion: stool softener, Osmotic laxative,
 
Fibre supple­ments: insoluble + soluble
 
Encourage fluid intake
 
Encourage PA

Interv­entions before­/after surgery

ERAS protocol
EN (head & neck ca)
Indicated when:
 
5% LOW prior to surg, OR 10% LOW 6/12
 
Ongoing dehydr­ation or dysphagia or pain associated with E+D
 
SPL - severe aspiration 65+ years old
 
High risk of long term swallowing diffic­ulties - e.g. high doses of chemo + radiation planned after surgery
PN
When indicated